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Antistreptococcal treatments could have therapeutic potential for psoriasis, but their efficacy is uncertain because of limited evidence, according to a recent literature review. Tonsillectomy, however, emerged as a potentially beneficial antistreptococcal option.

Authors of the review, which appears in , called for more study into both topics, as well as research into whether anti-inflammatory properties -- not antistreptococcal properties -- were the key to favorable results for a major antibiotic included in the review.

Researchers ultimately analyzed 50 studies encompassing 1,778 patients and various antistreptococcal treatments. In 14 studies (409 patients), tonsillectomy yielded favorable outcomes for improved symptoms and quality of life. Penicillins and aminopenicillins were the most studied treatments overall and generated mixed results, with some improvement shown in patients with guttate psoriasis but no significant changes in other investigations.

Rifampin demonstrated positive results while macrolides showed varying effectiveness.

Co-author Jessica Kaffenberger, MD, is clinical associate professor of dermatology and division director of medical dermatology at The Ohio State University Wexner Medical Center. Her exchange with the Reading Room has been edited for length and clarity.

What was the motivation for undertaking this systematic review, and what were the review's objectives?

Kaffenberger: We had several patients come in with streptococcal-induced psoriasis flares, and that inspired us to take a deep dive into the available evidence of the potential role of antistreptococcal therapies in the treatment of these patients.

The association between Streptococcus pyogenes infection and both guttate and plaque psoriasis has been well documented. It is theorized that treating an associated streptococcal infection in a patient with psoriasis will lead to improvement of the psoriasis. However, the effectiveness of treating psoriasis in patients who have concurrent streptococcal infection with systemic antibiotics or tonsillectomy is still a matter of debate.

Therefore, our objective was to analyze antistreptococcal therapies' effectiveness in improving psoriasis.

What were the key findings?

Kaffenberger: Rifampin was the most effective antistreptococcal therapy in psoriasis, while the penicillins and aminopenicillins had more mixed results, with potentially more modest improvement. Tonsillectomy was also helpful for these patients.

Did anything surprise you about the review or its findings?

Kaffenberger: Rifampin's improvement in PASI [Psoriasis Area and Severity Index] and PGA [Physician Global Assessment] scores was seen in patients with and without concomitant strep infection. Thus, rifampin's anti-inflammatory properties may be playing more of a role than its antistreptococcal properties.

What are your take-home messages for clinicians regarding these findings?

Kaffenberger: There was considerable variability in dosage, treatment length, and even testing for Streptococcus in the studies. However, in regard to rifampin data, our review suggests that the anti-inflammatory properties of the antibiotic are more effective than the antistreptococcal properties.

Thus, clinicians could consider treating guttate psoriasis with a strong anti-inflammatory antibiotic regardless of streptococcal status.

However, it is also very important to weigh the risk of antibiotic resistance -- especially in patients with recurrent streptococcal infections. Further studies are needed to compare the use of antibiotics against other treatments such as DMARDs or biologics for the treatment of streptococcal-induced psoriasis, so that we can determine whether antibiotics are needed at all in these patients.